Provider First Line Business Practice Location Address:
5213 FREDRICK AVENUE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ST JOSEPH
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64506-3263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-676-2525
Provider Business Practice Location Address Fax Number:
816-676-2533
Provider Enumeration Date:
02/10/2006